As a psychiatrist do you/would you feel comfortable prescribing meds like anti-hypertensives?

[chajjohnson]

I have chosen to apply to psychiatry, but I was torn between psych and primary care fields as I don't want to forget every other system of medicine I've spent the last 3 years learning. I was considering applying FM/IM-Psych combined programs but it just didn't work out geographically. On the interview trail I spoke with a psychiatrist who does a lot of community visits with patients and they said they will end up prescribing "simple" meds like anti-hypertensives or metformin to patients because they are often the only physician these patients will see. The psychiatrist does discuss tricky cases with primary care colleagues, but said they are becoming more comfortable with these meds and that needs to happen less and less. That sounded very interesting to me, needing to at least be up to date on current HTN and DM diagnostic criteria and first line medications. As a psychiatrist, is it common to be in a position like this, where you are providing primarily psychiatric care but doing some low-level primary care stuff as well? Besides community visits, I imagine this type of thing would be somewhat common in places like state mental hospitals or JDCs.

---

Members don't see this ad.

 

[futuredo32]

I did a few times when I first started but I asked my malpractice Co and they said it was a big no no, they said it was practicing outside the scope of my profession. I do prescribe propranolol for patients for performance anxiety. It's hard for me because I SO miss the rest of medicine.

 

[Mad Jack]

It's a good way to get in serious trouble

 

[SpongeBob DoctorPants]

Well, as a child psychiatrist I use meds like clonidine and guanfacine all the time (though not necessarily for blood pressure). I have used metformin for controlling weight gain associated with antipsychotic use, but I'm not managing diabetes. I have ordered one-time prescriptions for patients who may be new to the area and don't have a PCP yet, but only continue what they are already on. In the inpatient setting, however, I have often managed blood pressure and diabetes meds for adult patients while they are in the hospital. For anything I don't feel comfortable with, I get a medical consult. And since I didn't receive any training in residency or fellowship with regard to general pediatric medicine, I certainly wouldn't attempt to manage health problems in children.

 

[NontradCA]

I think the issue becomes once you start a med you're responsible for following up with it, and whatever disease process warrants the prescription.

Try consults? Or FM/Psych in an academic setting.

 

[JustAGuy]

It seems ridiculous to think that after 4 years of medical school, 3 licensing exams, and an internship that following a JNC algorithm for managing hypertension would be beyond the scope of practice for a psychiatrist. It's cool for an FNP to prescribe Zyprexa but not for me to start someone on a little Lisinopril or albuterol?

I think it comes down to the severity of the problem, the patient's access to primary care services, and the comfort level of the psychiatrist. Psychiatrists should be giving this some serious thought and taking a more active role providing better care for some of the more common medical issues seen in our seriously mentally ill patients (tobacco use, CV illness, metabolic issues). The APA even approved a statement saying as much, declaring that screening and, yes, even treatment, is an essential component of good psychiatric practice.

http://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2015.9b4

 

[TexasPhysician]

On an inpatient setting, you may be in charge of every med the patient is on.

Outpatient, I would stick to treating the psych conditions which potentially includes antihypertensives, thyroid meds, metformin, cholesterol meds, etc. Knowledge of these meds will be important.

 

[chajjohnson]

It seems ridiculous to think that after 4 years of medical school, 3 licensing exams, and an internship that following a JNC algorithm for managing hypertension would be beyond the scope of practice for a psychiatrist. It's cool for an FNP to prescribe Zyprexa but not for me to start someone on a little Lisinopril or albuterol?

I think it comes down to the severity of the problem, the patient's access to primary care services, and the comfort level of the psychiatrist. Psychiatrists should be giving this some serious thought and taking a more active role providing better care for some of the more common medical issues seen in our seriously mentally ill patients (tobacco use, CV illness, metabolic issues). The APA even approved a statement saying as much, declaring that screening and, yes, even treatment, is an essential component of good psychiatric practice.

http://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2015.9b4

I completely agree. The JNC 8 guidelines are literally a flowchart filled with medications that are generally very safe, especially compared to some psych meds. I get that US physicians practice CYA medicine more than anything else, but it seems strange psychiatrists, board certified MDs with lots of primary care experience, couldn't prescribe these meds for HTN. Especially if a psychiatrist is the only doctor a patient sees or trusts.

 

[Shikima]

I will provide a refill for an established patient.

 

[wolfvgang22]

Short answer: yes.

If a primary care physician is available, I utilize him or her as much as possible. Practically speaking, I don't mess with medications other doctors are managing unless absolutely necessary to avoid confusion. If a primary care physician is not available, I do what I'm comfortable with considering my level of training and experience and seek guidance from an expert when I'm not 100% sure. I try to stick to the standard of care in my community for psychiatrists.

 

[hamstergang]

It seems ridiculous to think that after 4 years of medical school, 3 licensing exams, and an internship that following a JNC algorithm for managing hypertension would be beyond the scope of practice for a psychiatrist. It's cool for an FNP to prescribe Zyprexa but not for me to start someone on a little Lisinopril or albuterol?

Keeping up to date with the literature in psychiatry alone takes up enough time. Relying on your med school experience and 4 months of IM in intern year to be sufficient years down the line isn't good care for the patient.

And this has nothing to do with FNPs. We shouldn't water down physician care just because others are essentially trying to.

 

[PikminOC]

It seems ridiculous to think that after 4 years of medical school, 3 licensing exams, and an internship that following a JNC algorithm for managing hypertension would be beyond the scope of practice for a psychiatrist. It's cool for an FNP to prescribe Zyprexa but not for me to start someone on a little Lisinopril or albuterol?

I think it comes down to the severity of the problem, the patient's access to primary care services, and the comfort level of the psychiatrist. Psychiatrists should be giving this some serious thought and taking a more active role providing better care for some of the more common medical issues seen in our seriously mentally ill patients (tobacco use, CV illness, metabolic issues). The APA even approved a statement saying as much, declaring that screening and, yes, even treatment, is an essential component of good psychiatric practice.

http://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2015.9b4

Apa is in cahoots with apbn to make us do only their "approved" cme.
I dont care what apa says. Are they going to back you in a mp case or just keep milking you for cme?

 

[nitemagi]

I feel completely comfortable, but I don't do it much for the reasons mentioned. I'll prescribe metformin for those on APs where weight gain is an issue as well, but then have to do other monitoring (if they'll comply).

 

[SeniorWrangler]

The problem is that if you refill it once, they'll expect you to keep doing it, and then you're managing the patient's hypertension as well as their depression or whatever. And if their hypertension is poorly controlled, or if it's secondary hypertension due to renal vascular issues and you missed it because you're a psychiatrist and don't think about that stuff, that's on you too.

 

[deleted407021]

Does the opinion that psychiatrists ought to stick to psychopharm apply to C/L docs?

 

[michaelrack]

Does the opinion that psychiatrists ought to stick to psychopharm apply to C/L docs?

My opinion (whatever it is ) is the same for C/L and non-C/L psychiatrists. C/L psychiatrists are not better equipped to practice general medicine than non-C/L psychiatrists

 

[splik]

Does the opinion that psychiatrists ought to stick to psychopharm apply to C/L docs?

It would be even more inappropriate for a C/L psychiatrist to be treating non-psychiatric conditions given that by definition the patient has a real doctor responsible for their care who should be managing their medical problems. As consultants we don't prescribe anyway, we only make recommendations to the patient's primary treating physician on how to manage the patient. Much of the time consultations do not involve recommending medications at all.

 

[pisekar]

I have no problem prescribing anti-hypertensive or other medications. However, when I have a very limited time for the interview, I do not want to ask questions about irrelevant medical problems. You already chose to apply psychiatry, so I would recommend you to rank biological programs highly compared to the psychotherapy-heavy ones. After the residency, you can apply some non-traditional fellowships such as palliative care etc. Also, I would recommend you to focus on yourself why it is important (or more valuable) for you to prescribe (lisinopril) rather than (sertraline). To me, both are medications for medical problems.

 

[Blitz2006]

It seems ridiculous to think that after 4 years of medical school, 3 licensing exams, and an internship that following a JNC algorithm for managing hypertension would be beyond the scope of practice for a psychiatrist. It's cool for an FNP to prescribe Zyprexa but not for me to start someone on a little Lisinopril or albuterol?

I think it comes down to the severity of the problem, the patient's access to primary care services, and the comfort level of the psychiatrist. Psychiatrists should be giving this some serious thought and taking a more active role providing better care for some of the more common medical issues seen in our seriously mentally ill patients (tobacco use, CV illness, metabolic issues). The APA even approved a statement saying as much, declaring that screening and, yes, even treatment, is an essential component of good psychiatric practice.

http://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2015.9b4

+1

I agree with this. This issue always baffles me. When I was an intern on medicine, I had 0 issue with prescribing common "medicine drugs" like protonix, norvasc, augmentin on the floors without really asking a senior. But psychiatric drugs like lithium, clozaril, depakote are serious meds, with serious complications (potentially), I would always run by my attending before prescribing it and discuss what I should follow-up on. I don't understand how following up on a patient on lithium (kidneys, thyroids) is any different than following up a patient on norvasc (which I think we can all agree on is 'safer' drug than lithium).

I feel like in the U.S everyone is so "specialized" that everyone is only comfortable with prescribing their own 5 drugs. In the UK, physicians are more "well-rounded, holistic". But yes, I am aware that the medico-legal environment in the States is much different than the rest of the world...

Just my 2 cents.

 

[DisorderedDoc417]

If they’re an inpatient client... you may be their primary and occasional PRN situations absolutely arise. But if someone else is available by consult, or if they are utilizing their PCP, the risk of causing harm or getting into murky waters outweighs the “fun” of pretending to play internist. Our meds are way cooler anyways.

 

[J ROD]

I feel comfortable with basics. If I thought they will not follow up with anyone but myself then I would. Usually no problem doing it inpatient. But to follow up with FM/IM

 

[AlDante]

What a coincidence. I just wanted to ask a very similar question and then discovered this thread.

In German inpatient psychiatry, some psychiatrists feel comfortable prescribing antihypertensives, statins, etc. to their patients whereas others run a consult for every tiny detail. Length of stay for non-acute psychiatry admissions is usually around a month here, sometimes up to three months. There is certainly no fear of medico-legal problems here.

My question was very similar to that of the OP: How common is it in U.S. inpatient psychiatry to act as a "temporary PCP"? I would certainly never try to outsmart a patient's family doctor, or start an insulin therapy on a newly diagnosed type 1 diabetic, but how common is it in the U.S. to handle the "everyday health problems" of inpatients without a PCP?

 

[MedMan80]

What a coincidence. I just wanted to ask a very similar question and then discovered this thread.

In German inpatient psychiatry, some psychiatrists feel comfortable prescribing antihypertensives, statins, etc. to their patients whereas others run a consult for every tiny detail. Length of stay for non-acute psychiatry admissions is usually around a month here, sometimes up to three months. There is certainly no fear of medico-legal problems here.

My question was very similar to that of the OP: How common is it in U.S. inpatient psychiatry to act as a "temporary PCP"? I would certainly never try to outsmart a patient's family doctor, or start an insulin therapy on a newly diagnosed type 1 diabetic, but how common is it in the U.S. to handle the "everyday health problems" of inpatients without a PCP?

Depends on the setting, in an academic institution when residents are readily available for medicine consults expect to consult on every little thing. I would assume that certain places out in the boondocks may be harder to wait for a medicine consult (could take some time) so I would surmise that one would act in the best interest of the patient. I have never seen however somebody start an antihypertensive and continue it's management in the outpatient world..

 

[deleted407021]

How about other specialties? For instance, is a cardiologist running any kind of professional risk if he or she prescribes a drug for gastric reflux in a patient whose CVD they're managing?

 

[splik]

How about other specialties? For instance, is a cardiologist running any kind of professional risk if he or she prescribes a drug for gastric reflux in a patient whose CVD they're managing?

Cardiologists are usually board certified in internal medicine or have at least completed an IM residency and this could practice the range of IM if they so wished. But usually they make more money sticking to cards. Also chest pain is within the scope of cardiology so it would be well within their remit to start someone on a PPI. That said GERD drugs are available OTC and an inpt psychiatrist would not think twice about rxing for GERD or whatever in that setting - but there is no need to do so in an outpatient setting and to do so without exam or consideration of further workup could lead to a malpractice claim (for example if the pt had Barrett's esophagus that went undiagnosed and later developed esophageal ca)

 

[futuredo32]

I am unique I picked the wrong pony. I LOVED psych as a student but SO miss the rest of medicine. I keep up on medicine, read about it in my free time. My fantasy would be to get a 2nd residency in FP and do about 10-15 hours of therapy with or without med management. I did a TRI and DO TRIS at least where I did mine are not what I have read about MD intern years. No teams, its all you unless someone codes. With my application my age- med was a second career, and funding issues, I think my second residency is just a fantasy. I am praying I passed the ABPN, if God grants that miracle, I will volunteer at a free FP clinic and apply. But realistically, I feel comfortable prescribing a lot of meds FP or IM docs would but don't due to malpractice. Who suffers? My patients who are afraid to go to their pcp.

 

[michaelrack]

regarding INPT: it varies. Sometimes a primary care doc or primary care NP does an H and P on every patient and handles all the medical problems. On some units the psychiatrist has to deal with reluctant consultants. On one of the psych units that I have moonlighted at on weekends (as a psychiatrist), I have had to deal with fractures by discussing them with the orthopedist over the phone because the orthopedist didn't want to come in and the hospitalist said ti was a non-IM problem.

 

[FlowRate]

How about other specialties? For instance, is a cardiologist running any kind of professional risk if he or she prescribes a drug for gastric reflux in a patient whose CVD they're managing?

Around here, a lot of the CHF docs are also their patients' PCP. But, like splik said, they actually had that training already.

There aren't that many other specialties that I can think of who see their outpatients frequently and whose patients also don't follow-up with their PCP.

 

[PikminOC]

Cardiologists are usually board certified in internal medicine or have at least completed an IM residency and this could practice the range of IM if they so wished. But usually they make more money sticking to cards. Also chest pain is within the scope of cardiology so it would be well within their remit to start someone on a PPI. That said GERD drugs are available OTC and an inpt psychiatrist would not think twice about rxing for GERD or whatever in that setting - but there is no need to do so in an outpatient setting and to do so without exam or consideration of further workup could lead to a malpractice claim (for example if the pt had Barrett's esophagus that went undiagnosed and later developed esophageal ca)

Correct.

Many midlevels have a physician collaborater to hide behind when things go wrong, so they are more apt to be looser with prescriptions. It is certainly not expertise that has them doing all this out of scope prescribing

 

[Candidate2017]

It seems ridiculous to think that after 4 years of medical school, 3 licensing exams, and an internship that following a JNC algorithm for managing hypertension would be beyond the scope of practice for a psychiatrist. It's cool for an FNP to prescribe Zyprexa but not for me to start someone on a little Lisinopril or albuterol?

Don't compare us to family med. Those docs and NP do a piss poor job of managing psych patients. Ten minutes a pop, a pill for every ill is how they practice.

Second, because we can doesn't mean we should. Psychiatric patients have long term nonpsych issues that require long term nonpsych care. They need to establish a relationship with a PCP. If they are unwilling to make appointments with a PCP and get regular check ups, they are NONCOMPLIANT with their psychiatric treatment as far as I'm concerned because seeing a PCP is part of every psychiatric plan. Our time is precious and better spent dealing with psych issues, not play fam med NP. We are specialists.

On our unit we can call consults but we are comfortable restarting or adjusting home meds or dealing with acute issues. However I think it's inappropriate most times to start a med for chronic HTN. I will point it out, instruct patients to follow up, and make a note in their discharge summary for their PCP. I am no more responsible for managing their chronic nonpsych conditions than I am for driving them to Al Anon meetings. I provide them guidance but ultimately their well being depends on their willingness to address issues and engage resources I've pointed out.